An RN's thoughts on the health care law

[RN4MERCY]

I've been following the debate about the health care law and it seems like most commenters are totally for it or adamantly against it. I've been watching my family, friends, and patients face bad choices and rationed health care because of our current health insurance system. What I really want to know is if this law will fix it.

First, let's look at some of the key parts of the Affordable Care Act (ACA), most of which are phased in by 2014:

- The best parts of the law are the provisions that people cannot be denied health coverage because of pre-existing conditions, that insurers can not drop you when you get sick, and that eliminate annual and lifetime caps on coverage. What worries me are the loopholes that insurance company lawyers will use to continue to cherry-pick who they cover. For example, the law doesn't say how much they can charge to cover people with pre-existing conditions.

- Almost everyone (even the insurance companies) agrees that it's good to let parents keep their children, up to the age of 26, on their health insurance (if they have it).

- Large companies that don't give their workers health insurance will have to pay $2,000.

- People who do not have health insurance where they work and choose not to buy it will have to pay a penalty. Is the individual mandate a fee, a tax, or a penalty? I don't really care what we call it. I understand why everyone should be part of the healthcare system. Medicare does this, covering everyone 65 and over. The individual mandate is a clumsier way of creating one risk pool, through private insurance companies. I've don't like it because it requires people to give money to profit-making insurance companies.

- If you are very low income, you may qualify for a government-funded subsidy to buy insurance through a health exchange, or, for the most low income, become eligible for Medicaid which is set to expand.

- It shrinks the Medicare donut hole in prescription drug coverage, where there's coverage to a certain point and then nothing until a higher spending cap is reached. Since 2010, 5.2 million seniors and people with disabilities have saved $3.7 billion on prescription drugs. I believe the donut hole should be entirely eliminated.

- All insurance plans will be required to include preventative care (i.e. mammograms, vaccinations, colonoscopies, physicals) with no co-pay, by 2018.

- Medicare coverage will now include an annual physical and no co-pays for preventative services.

- Before, small businesses paid as much as 18% more than larger businesses for premiums. Now, they will get tax credits (up to 50% of the cost of premiums) for offering health insurance to their workers. In 2011, this affected 2 million employees.

- Pharmaceutical, medical device manufacturers and health insurance companies will have their taxes increased. I agree with this. This law gives them millions of new customers. They can help pay.

- The law increases funding for community health centers, one of the best provisions of all.

- For the first time, the law taxes health benefits, and the main target is the comprehensive, best plans. In 2018, those plans (more than $10,200/single; $27,500/family) will be taxed. The insurance company has to pay, but they're going to pass the cost along to anyone lucky enough to have a good plan. I think this will push more people into plans that cover fewer health needs and have large out-of-pocket costs.

- In 2013, if you make more than $200,00 (individual) or $250,000 (family), you will pay a Medicare tax on investment income (before Medicare tax was only on wages).

- The Medicare tax rate goes up to 3.8%, from 2.9%.

Although the advocates for the law say that it will bring down health care costs. I believe that some of these benefits are over-stated and ignore some remaining very large problems.

What the law doesn't or maybe won't do:

- Despite the all the claims about cost controls for individuals and families, most of them are weak. Insurance companies, drug companies, and hospitals will still largely be able to charge what they want. Although there are limitations on rate increases, this is not enough protection, 9% increases for several years is just as untenable (although it is better than the current, unfettered, increases).

- I expect that people will continue going bankrupt because of high medical bills or choosing to skip or delay doctor visits or needed treatment.

- Insurance companies will still be able to deny care recommended by a doctor using the same excuses ("experimental," "not medically justified," etc) as now.

- I read that the non-partisan Congressional Budget Office said that up to 27 million people will still have no health coverage. Since the Supreme Court decision allows individual states to opt out of the Medicaid expansion for low income people without a federal penalty, that number will probably grow.

- Some people are worried that employers will drop existing coverage because the exchanges will now be a more affordable option. I'm not too worried since before this law, employers could drop or reduce coverage any day they wanted (and many did). There's nothing in ACA which makes it more attractive to drop coverage, in fact they might have to pay a penalty for dropping coverage.

- The law promotes IT systems in healthcare, many of which are wasteful and have been used by some employers to erode RN clinical judgment.

- There are similar misguided incentives for "wellness" programs that penalize people who have diabetes, high blood pressure, or other medical conditions often beyond their control.

- The windfall for insurance companies, big pharmaceutical firms (who were exempted from strong cost controls to win their support for the law), further strengthen a healthcare system already too focused on profits rather than patient need.

For me, the bottom line is the ACA law didn't go far enough. Insurance companies are going to be a little more restricted more than they were in the past. It will help some people but doesn't cover all Americans.

Polls show that a majority of Americans would rather that Medicare cover everyone. We would still have to work to improve it, but it would be easier and more cost-effective. It would eliminate the higher administrative costs (ACA limits insurance companies to 15%, even assuming they don't find ways around that, Medicare's is 3%) and the corporate profits - billions of dollars removed from the health care system and not spent on health care.

[That Guy, BSN, RN, EMT-B]

I dont care if more people have it. I care about the bottom line: Cost to me for my services. How does this really help me at all? How will this prevent costs from rising?

[RN4MERCY]

I suppose that depends on your personal situation, in terms of how it's going to help and what it's going to cost. From all the studies I've seen, I believe costs over-all are going to continue to rise for all of us. We certainly spend much, much more, per capita, than other OECD nations, and our costs rise at a significantly faster rate. Economists and health policy experts assert that's because we don't have some form of a single payer system that covers everybody, assuring uniform and equitable benefits--like Medicare.

http://www.oecd.org/dataoecd/46/2/38980580.pdf

[Ludlow]

Thanks for this clear explanation of where we're at in the health care coverage world. The sooner we get to Medicare for All the happier I'll be.

[tntrn, ASN, RN]

Good synopsis. I really hate the part of punishing people who can afford fhe best plans. It serves no purpose. It is the Affordable Act...if they can adford it, why penalize them for that with higher taxes?

[Ludlow]

tntrn, what are the 'higher taxes' you're refering to? If you have insurance and like it you can keep it. If you refuse to get insurance, you will be fined. The fine was described by Justice John Roberts as a tax. Most taxes are added to things we buy: gasoline, TVs, property. This is a tax or fine if we don't do someting: get health insurance.

So I imagine those who can afford it will, as a matter of personal responsibility, buy it. Those who can't afford it will receive subsidies. Those who won't will be taxed/fined (and the fine is not that much and not much happens to you if you don't ever pay it--unless congress changes that part of the law).

[Ludlow]

tntrn, On second look I see you might be talking about the tax on insurance plans if they cost more than $10,200/yr per single or 27,500/yr per family. I agree there, that sucks and is a stupid way to get revenue. It was a concession to republicans. Many of the stupid things in the bill were concessions trying to get republican votes for the bill. The concessions were added in but not one republican voted for the bill.

[tntrn, ASN, RN]

Ludlow, not trying to be obtuse, but i dont understand why a higher tax would be something republicans would want.

[RN4MERCY]

Clearly, even tax-aphobics realize we can't cut our way out of the deficit, and no acceptable path away from the edge of that cliff can avoid the revenue side. According to a CNN poll last year "tax the rich" initiatives are supported by 55% of those voters who identify themselves as republicans.

In considering this further, I'm wondering why is there just the one break point for the added tax? Why not escalating rates? The higher the bracket, the higher the percentage. For that matter, why not a return to such a setup for all income? That's what we used to have — it was known as a "progressive” tax for those who don't remember. It was part of a quaint concept called "fairness.”

The idea was to better share the nation's wealth rather than let just a few hoard it. It could then be used for the greater good, like garbage collection, police and fire protection, and education. Shouldn't healthcare be one of those public "goods" as well?

There are decent arguments about the so-called "Cadillac" plans: whether, like the luxury cars, they are wasteful and do more harm than good. For instance, I see weathier patients and/or those with "better" insurance get more testing--not because the tests are really necessary to confirm or exclude a diagnosis, but because of likelihood the bill will be paid. I see other patients with the same kinds of diagnoses who do just fine without all the sophisticated and expensive tests, because their doctors and nurses relie on critical thinking skills and the application of experience and good judgement in non-routine situations.

But those who can pay for the "Cadillac" plans probably can also afford a little more to make sure nearly everyone else at least has the basics. It's essential for the overall health of a nation that provided them the opportunity to prosper. The hard fiscal realities are getting more difficult to ignore, prompting even republicans to say "yes" to new taxes.

Poll after poll shows that the American people want higher taxes. That's not the same as liking higher taxes. The people have simply concluded that in order to have things like social security and access to medical care higher taxes are preferable to the alternative.

Ultimately though, I think the argument can be made that if we expanded and improved Medicare to provide everyone with a comprehensive set of benefits and single excellent standard of care, we would realize a great savings by eliminating high overhead costs, administrative waste, and expenses for marketing and advertising.

[guest416560]

What you fail to realize that it really doesn't matter if you have insurance if nobody accepts it. I rarely see Medicaid patients because of the low reimbursement. Just because you add millions to the Medicaid roles doesn't mean they will have access to healthcare. To help pay for the new entitlement Obama plans to lower reimbursement for Medicare. If the reimbursement for Medicare gets lowered not only will I quit seeing all Medicaid patients but I will also quit seeing Medicare patient.

I'm a FNP but was a MBA before getting into healthcare. I run my business like a business. I fear I will only be seeing PPO and cash paying patients. Obamacare has provided a slippery slope by providing patients with insurance and few providers willing to see them because of low reimbursement rates.

[tntrn, ASN, RN]

I am shaking my head at the news that poll after poll show americans want higher taxes! Astounded, really. Must be the 49% who pay no income taxes at all. And whose business is to assume that those who can afford a cadillac plan can also afford to pay more. That irritates me.

[RN4MERCY]

I'm not sure anyone's missed the point here. It's just that if more money were going into the public system to pay for actual care instead of being diverted into private coffers to pay for marketing, advertising and glistening corporate headquarters, providers would get paid more fairly and more patients who need comprehensive care would receive it. That's not happening now, and I think there are loopholes in the new law that will find people falling through the cracks.

It's not fair to deprive the public system of resources and then call it a failure; administrative costs are low with publicly administered and financed systems. Whether or not the states expand medicaid remains to be seen; clearly that was the intent of the law. Some states like Vermont and California are in the process of accepting the challenge put forth by President O'Bama to come up with a better, more inclusive and equitable publicly financed system such as single payer.

Only about 20% of the population at any given time requires medically necessary care for an assortment of chronic, acute, or traumatic illnesses or injuries. If everyone who is able pays into the system, the benefits--whether they include screening and prevention, dental/vision, medications, homecare supplies, and if needed, acute care services, will be available, accessible and covered at the time of need.